PARENT GRANT PRCIS- GRUDZEN ET AL. PRIMARY PALLIATIVE CARE EDUCATION, TRAINING, AND TECHNICAL SUPPORT FOR EMERGENCY MEDICINE (PRIM-ER) Objectives The overall goal of the PRIM-ER project is to determine the effectiveness of Primary Palliative Care for Emergency Medicine (PRIM-ER) on older adults with serious illness. Design and Outcomes PRIM-ER is a pragmatic, cluster-randomized stepped wedge trial to test the effectiveness of PRIM-ER in 35 Emergency Departments (ED). Medicare claims data will be used to assess the following outcomes during the evaluation phase of the project: Primary: ED disposition to an acute care setting Secondary: Healthcare utilization in the 6 months following the ED visit; and survival following the index ED visit. It will also determine the site, provider, and patient-level characteristics, including the implementation fidelity associated with variation in impact of PRIM-ER using the RE-AIM framework. Interventions and Duration PRIM-ER includes: 1) evidence-based, multidisciplinary primary palliative care education, 2) simulation-based workshops on communication in serious illness, 3) clinical decision support (CDS), and 4) provider audit and feedback. The specific aims are divided into: 1) a Pilot Phase, in which we tailored the protocols to a diverse ED context and tested the intervention at two sites; and 2) an Implementation and Evaluation (IE) Phase, in which we will test the intervention using a stepped wedge design in 33 EDs over 24 months. Sample Size and Population Participants in the quality improvement (QI) intervention will consist of key informants interviewed to understand the unique workflows of each participating site, and emergency providers, nurses, care managers, and social workers who will receive the education and clinical decision support interventions. The analysis will use Medicare claims data of approximately 300,000 patients to assess the impact of PRIM-ER.